ABSTRACT: Increasing numbers of women and adolescent females are incarcerated each year in the United States and they represent an increasing proportion of inmates in the U.S. correctional system. Incarcerated women and adolescent females often come from disadvantaged environments and have high rates of chronic illness, substance abuse, and undetected health problems. Most of these females are of reproductive age and are at high risk of unintended pregnancy and sexually transmitted infections, including human immunodeficiency virus (HIV). Understanding the needs of incarcerated women and adolescent females can help improve the provision of health care in the correctional system.

Background

Between 1990 and 2009, the number of incarcerated women increased 153% (1). Most women in correctional facilities are incarcerated for nonviolent crimes. Drug offenses are the most common felonies committed by women in both federal (72%) and state (34%) prison systems, and are the second most common offense committed by women in local jails (30%) (2). By the middle of 2009, 106,362 women (6.9% of all prison inmates) were incarcerated in federal or state prisons, and by the middle of 2011, 93,300 women (12.7% of all jail inmates) were incarcerated in local jails (3, 4). In 2010, 306,498 females younger than 18 years were arrested, representing 29% of all juvenile arrests (5). Juvenile offenders may be housed in juvenile detention homes or residential correctional facilities or, in some cases, in adult prisons or jails.

Incarcerated women and adolescent females often come from economically, educationally, socially, and emotionally disadvantaged environments; a disproportionate number have acute and chronic illnesses, substance abuse problems, and undetected health issues, including reproductive health needs. In one study, 27% of incarcerated women had chlamydia and 8% had gonorrhea, compared with rates of 0.46% and 0.13% in the general population, respectively (6). In 2008, 2% of women in state and federal prisons were known to be infected with human immunodeficiency virus (HIV) (7). Fifty-six percent of women in federal prisons and 62% of women in state prisons were parents of one or more minor children, and 19% of these children were in the care of someone other than a family member during the mother’s incarceration (8).

Approximately 6–10% of incarcerated women are pregnant, and are mostly incarcerated in local jails (9, 10). There are few studies about birth outcomes for women who continue pregnancies during incarceration. Although a woman retains her legal right to an abortion during incarceration, a woman’s experience in attempting to obtain an abortion varies widely by state, region, and individual prison (11, 12). In a survey of correctional health officials, 68% indicated that women in their prisons were allowed to have an elective abortion, but only 54% helped arrange appointments (11).

Sexually transmitted infections and pregnancies may result from sexual victimization of women during incarceration. In a survey of local jail inmates using audio computer-assisted self-interviews to maximize confidentiality and reliability, 5.1% of female inmates reported sexual victimization (13). Of these, 3.7% of women experienced sexual victimization by another inmate and 2.0% reported sexual victimization by a staff member (13). In a similar survey of state and federal prison inmates, the rate of sexual victimization among men and women was 4.5% (14). Total rates for women were not presented, but rates were as high as 10.8% at some prisons, with sexual victimization by a staff member reported by up to 5.3% of women (14).

Mental health disorders and substance abuse are common among incarcerated women. Sixty-nine percent of women admitted to local jails met the criteria for substance dependence or abuse (not including tobacco use); dependence was diagnosed more commonly among women than among men (15). Rates of mental health problems among women inmates ranged from 61% in federal prisons to 75% in local jails (16). Incarceration is an important risk factor for suicide by adolescent inmates (17). More than 50% of women in jail reported a history of physical or sexual abuse, and this rate is as high as 92% among female juvenile offenders in California (18, 19).

Medical Care Availability and Access

Although most state and federal prisons provide some level of care to prisoners, availability and access to medical care in jails is variable. The short and often unpredictable duration of incarceration in local jails often makes provision and continuity of care difficult. In addition, systems of care vary in state and local prison and jail settings. Services at state prisons and jails may be provided on site by health care providers, by arrangements with local hospitals or clinics either on site or by inmate transport, or by an on-site health care provider contractor. Historically, health care was delivered by way of a “sick call,” where an inmate notified a guard or other designated authority of the need for medical attention. A sick call system does not allow for provision of primary or preventive care and health education. Although many facilities have moved to systems that provide primary care, the increase in the number of inmates makes provision of adequate care difficult. In addition, women are often housed in facilities with predominantly male populations, which limits the availability of health services tailored to women’s needs. Financing of correctional facilities, including health care, depends on legislative appropriations that compete with other priorities. In general, Medicaid funding cannot be used for care for adults and adolescents in secure confinement.

No federal or state mandates require correctional health facilities to obtain accreditation, and there is no organization to which all facilities are accountable. Several organizations accredit prisons, but their standards only serve as guidelines and are followed voluntarily. These organizations include The Joint Commission, the National Commission on Correctional Health Care, and the American Correctional Association. Health care standards for jails, prisons, and juvenile facilities have been developed by the National Commission on Correctional Health Care, the American Correctional Association, and the American Public Health Association (20–23).

In general, care for incarcerated women and adolescent females should be provided using the same guidelines as those for women and adolescent females who are not incarcerated, with attention to the increased risk of infectious diseases and mental health problems common to incarcerated populations. Health care for incarcerated women and adolescent females is outlined in Table 1 (23, 24).

*If a juvenile is housed in an adult prison or jail, the recommendations under the juvenile facilities column should be followed.

†The request by either a patient or a physician to have a chaperone present during a physical examination should be accommodated regardless of the physician’s sex.

Data from Anno BJ. Correctional health care: guidelines for the management of an adequate delivery system. Chicago (IL): National Commission on Correctional Health Care; 2001. Available at: http://static.nicic.gov/Library/017521.pdf. Retrieved April 16, 2012; American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007; American College of Obstetricians and Gynecologists. Guidelines for adolescent health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011; American College of Obstetricians and Gynecologists. Guidelines for women’s health care: a resource manual. 3rd ed. Washington, DC: ACOG; 2007; American College of Obstetricians and Gynecologists. Well-woman care: assessments and recommendations. Washington, DC: American College of Obstetricians and Gynecologists; 2012. Available at: http://www.acog.org/~/media/Departments/Annual%20Womens%20Health%20Care/PrimaryAndPreventiveCare.pdf?dmc=1&ts=20120419T1033428879. Retrieved April 19, 2012; American Public Health Association. Standards for health services in correctional institutions. 3rd ed. Washington, DC: APHA; 2003; Cervical cancer in adolescents: screening, evaluation, and management. Committee Opinion No. 463. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:469–72; Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion No. 511. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1198–1202; National Commission on Correctional Health Care. Standards for health services in jails. Chicago (IL): NCCHC; 2008; National Commission on Correctional Health Care. Standards for health services in juvenile detention and confinement facilities. Chicago (IL): NCCHC; 2004; National Commission on Correctional Health Care. Standards for health services in prisons. Chicago (IL): NCCHC; 2008; and Health care for youth in the juvenile justice system. Policy Statement. American Academy of Pediatrics. Pediatrics 2011;128:1219–35.

Recommendations

Obstetrician–gynecologists should support efforts to improve the health care of incarcerated women and adolescent females at the local, state, and national levels. Activities may include the following:
— Gaining representation on the boards of correctional health organizations.
— Working in correctional facilities to provide services to incarcerated women and adolescent females and continuing care after the woman’s release, when feasible.
— Undertaking efforts to ensure that medical needs of incarcerated women and adolescent females are being addressed appropriately, such as by providing training or consultation to health care providers and correctional officers in prison settings.
— Advocating at the local, state, and federal levels for increased funding to provide access to necessary health care for incarcerated women and to restrict shackling of women and adolescents during pregnancy and the postpartum period (10).

Facilitate care provision by health care providers to incarcerated women and adolescent females (eg, allowing incarcerated women and adolescent females to enter through alternate entrances to avoid stigmatization in the waiting room or to be seen during off-hours).

Ensure that adolescents only be detained or incarcerated in facilities with developmentally appropriate programs and staff trained to deal with their unique needs. If they must be housed in adult correctional facilities, they should be separated from the adult population into an environment that is able to address their specific developmental needs (24).

Ensure that adolescents with serious mental disorders are not placed in detention when they do not face criminal charges. The placement of adolescents with mental disorders who have been charged with crimes and are able to be released from incarceration into a community mental health facility should be completed in a timely fashion.

Facilitate collaboration between medical schools and other health care professional schools and correctional facilities to improve care to inmates.

Obtain and support funding for research on the health needs of incarcerated women and adolescent females, the services they receive, the qualifications of the health care provider, the location of the service, and the outcomes of these services.

Support state and federal funding that increases access to necessary health care that includes not only disease-specific treatment, but also preventive services and access to qualified health care providers for incarcerated women and adolescent females.

Specific medical recommendations include the following:

Correctional facilities should be adequately funded to provide a continuum of care model providing female inmates with initial screenings, in-house services or referrals for preventive and curative care, including Pap tests and appropriate follow-up, health education, and adequate planning before release from correctional facilities.

Health care providers and other correctional facilities staff should receive appropriate training to provide care for female inmates, including the care of pregnant women (10).

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